Prepared for Ministry of Health
September 2003
1
Care Plus Formative Report CBG health research limited
DISCLAIMER
The views expressed in this occasional paper are the personal views of the authors and should not be taken to represent the views or policy of the Ministry of Health or the Government. Although all reasonable steps have been taken to ensure the accuracy of the information, no responsibility is accepted for the reliance by any person on any information contained in this occasional paper, nor for any error in or omission from the occasional paper.
CONTENTS
BACKGROUND TO THE RESEARCH 3
RESEARCH OBJECTIVES 3
RESEARCH DESIGN 3
Sample 3
Recruitment 3
Data collection 3
Data analysis 3
Key points 4
Evaluation Areas 6
Qualitative findings 7
Information provided to the PHOs 7
Interpretation of the eligibility criteria 8
Use of the information 10
Information management 10
Transferring HUHC patients to Care Plus 11
Identified Issues 11
Setting up Care Plus in practices 13
Practice requirements 13
PHO approaches to introducing Care Plus 13
Guidance and support for practices 13
Process for practices identifying and selecting patients 14
Management of Care Plus 15
Patient enrolments 15
Feedback 15
Validation of patient selections 15
Costs 16
Hidden costs 16
Quotation tables 17
Storage of Materials 21
Limitation of Liability 21
Use of information 21
Care Plus Formative Report CBG health research limited
BACKGROUND TO THE RESEARCH
The Ministry of Health has implemented a pilot of the Care Plus initiative in six Primary Health Organisations (PHOs). CBG Health Research Limited has been contracted to provide an evaluation of the Care Plus Pilot.
As a part of the evaluation, the Ministry of Health requested a report that describes the process of setting up Care Plus for the PHOs piloting the initiative. The following report describes the findings of a formative evaluation conducted with three Auckland PHOs.
RESEARCH OBJECTIVES
To understand the processes involved in setting up and implementing Care Plus from a PHO perspective.
RESEARCH DESIGN
Sample
Three Auckland PHOs were selected to complete the formative qualitative evaluation. At the time of the formative interviews (September 2003) one PHO had started implementing Care Plus with their practices; the other two PHOs were planning to commence at the end of the month.
Recruitment
Each PHO was contacted by telephone and invited to take part in a 1.5 hour interview with an experienced health researcher at a time and date convenient to them. The PHOs were sent a semi-structured interview guide before the interview.
Data collection
The interviews were all completed at the PHO premises in the month of September 2003. All discussions were recorded with the permission of the participants. Interviews were guided by a discussion guide to ensure that all relevant topics were covered. The interviews lasted one and a half to two hours.
Data analysis
The recorded data was openly coded, i.e. examined, compared and categorised. Each category of information was coded onto a framework that contained all of the major areas outlined in the discussion guide (appendix 1). The coded frame was sent to the respective PHO for validation of the interpretation of the information given during the interview. The coded frames were then used to create the report.
Key points
The Care Plus pilot was seen as an opportunity to see how the Care Plus criteria would apply to real practice populations, and of the practical issues in implementing a care planning approach. It was not regarded as a trial of a replacement for the High Use Health Card (HUHC).
Several possible reasons why HUHC patients, who may be eligible for Care Plus, might not be transferred were suggested:
· It may be administratively easier to renew the HUHC than start Care Plus
· Practices may prefer the security of receiving direct HUHC funding, rather than receive funding from Care Plus through their PHO
· Some practices might renew an HUHC, rather than transfer to Care Plus, as this could achieve the same level of practice funding for less clinical work.
· Not all HUHC patients can be classified as high need (12 retrospective visits does not always equate to past or current high need) and therefore may not benefit from Care Plus
· Patients transferred to Care Plus could lose Pharmacy HUHC subsidies
The capped amount for HUHC and Care Plus is seen as adequate. It is anticipated that the first one percent of Care Plus patients will be easy to identify through the practice staff’s experience and knowledge of their patients but the remainder may be more difficult. PHOs do not anticipate exceeding the financial cap and will employ risk management models.
Risk management of the capped amount for HUHC and Care Plus will be completed at a PHO level, across the entire PHO (or participating practices) population. One PHO is planning to initially focus on a practice allocation with the provision to later redistribute across the entire population if there is wide variability in Care Plus enrolment rates. The former risk management approach appears to have been adopted to facilitate the trial of Care Plus in practices with an existing high percentage of HUHC.
It is anticipated that meeting the first criterion (six visits) for Care Plus patients will be easy to identify through the Practice Management Software (PMS) systems and practice staff’s experience and knowledge of their patients.
While practices will receive some guidance as to the common chronic conditions that should be considered for inclusion in Care Plus, any disease coding lists will not be presented as exclusive. Patients with other less common conditions will be accepted into the programme.
PHOs have provided and will continue to provide a guide for the selection of patients to each practice but the patient selection is at the discretion of the practice team. Part of the selection process involves an intangible element of clinical knowledge and judgement to decide which patients would most benefit from a care planning approach.
PHOs are tracking enrolments, either by paper-based or electronic systems, as they happen.
The concept of Care Plus has been welcomed and is liked by practices but early feedback is that some practices have concerns that the funding for reviews is inadequate.
Some practices view Care Plus as legitimising the current practice of discounting for high need patients.
All of the PHOs have made provision for a project co-ordinator and/or clinical nurse specialist to oversee the implementation of the pilot at a practice level. PHOs’ early experiences of setting up Care Plus support this being a valuable step in establishing the initiative in practices. The set up and establishment of Care Plus was thought to require:
· Communication of the concept to GPs and Practice Nurses (PNs)
· Identification of a person who will be responsible for Care Plus within each practice
· Practice staff training to
o Use identification methods
o Set up care plans
o Manage the overall Care Plus patient portfolio
· Sharing of ideas on methods of identification, patient approaches, and care plan tips between practices via the resource co-ordinator
· Support to maintain identification systems and management of the Care Plus patient portfolio
Commencement of the pilot in the winter months has led to a slow uptake by practices.
Common problems that have been encountered to date:
· Nurses taking too much time to complete the care plans
· Practice staff perception that reviews will involve the same amount of work as the original care plan set up.
· Issue of loss of pharmacy co-payment in a transfer of HUHC to Care Plus
It was occasionally reported that patients may prefer to have unlimited subsidised visits (as with the existing HUHC) without any care planning.
Pharmacy reviews of patients who transfer from HUHC to Care Plus, and are taking a large number of medications, may offset the loss of the pharmacy HUHC subsidy, by identifying eligibility for the pharmacy prescription subsidy.
Care Plus is viewed as fitting with moves to increase the specialisation of practice nurses, patient self management and population based health. It was positioned as complementing other services such as hospice care and district nursing.
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Care Plus Formative Report CBG health research limited
Evaluation Areas
Some process evaluation areas, listed below, were suggested during the course of completing the formative evaluation:
· Measure the number of patients eligible for Care Plus within each practice
· Contrast and report practitioner selection of Care Plus patients with reference to each criteria
· Understand the methods employed by practice staff to select potential Care Plus patients, in particular, the use of “head held” patient lists (that is, lists of patients which are held only in a practitioner’s head, not written down anywhere)
· Examine the HUHC population with respect to expiry date of the card and assessment of any transfers or failure to transfer to Care Plus
· Measure the time involved in care plans, recall, reviews, patient identification and management of the Care Plus portfolio
· Identify the use, if any, of hospital and Emergency Department (ED) admission list and disease code guidance to identify Care Plus patients
· Assess the number of home reviews for terminally ill patients
· Examine practice attitudes and PHO approaches towards risk management inherent in the capped percentage
· Investigate the practice incentives for, and barriers to, transferring HUHC patients to Care Plus
· Investigate the intangible elements involved in the discretionary decision-making by practitioners as to the selection of Care Plus patients and who will most benefit from Care Plus.
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Care Plus Formative Report CBG health research limited
Qualitative findings
Information provided to the PHOs
All of the PHOs were in the process of developing Care Plus contracts which, at the time of interview, had yet to be signed. One of the PHOs had been provided with a Care Plus Ministry of Health (MoH) proposal and communications outlining eligibility criteria and the various considerations for the transfer of HUHC patients to Care Plus. This PHO noted that they had been extensively involved with the evolution and development of the Care Plus concept since its proposal by the Independent Practitioners Association Council (IPAC) to the Ministry of Health. The remaining two PHOs had received Care Plus service schedule documents from their respective District Health Boards (DHBs). They noted that the main communications regarding Care Plus had been via IPAC, other PHOs involved in the Care Plus pilot and DHBs.
For supporting quotation please refer to Table B, quote 1, Table C quote 1 and 2
The information that had been shared between the PHOs, MoH and/or DHBs and IPAC was deemed to have been comprehensive and had been used to inform the PHO plans for the implementation of Care Plus. It was noted that the MoH documentation had been slow to emerge and that this had delayed the pilot start from the proposed February 2003 commencement. One PHO noted that late communications regarding funding plans for Community Services Card (CSC) and non-CSC patients had proved problematic to the planning of a risk management strategy.
For supporting quotation please refer to Table C, quote 3
PHO staff perceived that issues relating to the integration of HUHC, CSC, the original IPAC proposal with Care Plus plans and funding considerations were responsible for the documentation delays. Concerns were relayed about practices capacity to start implementing Care Plus during the winter months when their workload is typically high.
For supporting quotation please refer to Table A, quote 1.
Despite the slow start, PHOs said that they had been preparing and priming their practices for the commencement of Care Plus. One of the PHOs ran the National Health Index numbers (NHIs) of the PHO enrolled patients through hospital databases to identify patients who had been admitted. Another PHO had requested an up-to-date list of CSC and HUHC holders within their enrolled population from HealthPAC. The CSC and HUHC register that was initially returned was not correct. This caused delays in the PHO’s plans to implement the Care Plus pilot.
For supporting quotation please refer to Table B, quote 2
Further preparation saw one PHO incorporate a change in their governance structure to add in a clinical board to oversee and support the implementation of Care Plus. Delays in the start date of the pilot were thought to have afforded this PHO the opportunity to gather more information about HUHC trends under the capitation model.
For supporting quotation please refer to Table C, quote 4
Care Plus was explained to be a care plan approach to patient care that will integrate a multidisciplinary team approach, specialisation for practice nurses, regular care reviews and the development of patient self management. It was described as an approach that aims to improve the health of the population and brings a timely relationship between care plans and illness that will encourage practices to increase the quality of care available to high need patients.
For supporting quotation please refer to Table A, quote 4 and 5,
Table B, quotes 3,4,11,
Table C, quote 5
The management of the capped percentage for Care Plus and HUHC was regarded as an area that required some attention in the evaluation. The capped enrolment for Care Plus was not considered to be a limiting factor for the pilot. It was anticipated that most practices would not reach the cap and/or the PHO would stay within the quota using various risk management approaches.
For supporting quotation please refer to Table A, quote 8,
Table B, quotes 5 and 17,
Table C, quotes 6 and 14.
Two of the PHOs were taking or planning to take a total population approach to afford Care Plus patient selection in practices that already have a high percentage of HUHC (up to five percent in some practices). One of the PHOs had opted to use a practice allocation approach with provision for redistribution of Care Plus places, between the participating pilot practices, depending on variability in uptake of places.
For supporting quotation please refer to Table A, quote 15.